What is the treatment for a buffalo hump (dorsocervical fat pad)?

Treatment of Buffalo Hump (Dorsocervical Fat Pad)

The treatment of buffalo hump should primarily focus on addressing the underlying cause, with surgical intervention reserved for cases causing significant physical or psychological discomfort that don't respond to medical management.

Underlying Causes and Initial Assessment

• Buffalo hump (dorsocervical fat pad enlargement) is commonly associated with Cushing syndrome, HIV-associated lipodystrophy, and long-term steroid therapy 1, 2
• When evaluating a patient with buffalo hump, assess for:
  • Signs of Cushing syndrome: central obesity, moon facies, facial plethora, purple striae, proximal muscle weakness 1, 3
  • HIV status and antiretroviral medication history, particularly protease inhibitors 2, 4
  • Long-term steroid use 1
  • Metabolic abnormalities: hypertension, hyperglycemia, dyslipidemia 1, 2

Treatment Approach Based on Etiology

1. Cushing Syndrome-Related Buffalo Hump

• Primary treatment focuses on addressing the underlying cause of hypercortisolism 1
• For adrenal causes (adrenal adenoma or adrenocortical carcinoma), surgical resection via adrenalectomy is the treatment of choice 1
• For iatrogenic Cushing syndrome (steroid-induced), gradual tapering of steroid dose when possible 1
• Screening for complications like osteoporosis is essential, with calcium and vitamin D supplementation recommended for patients on long-term steroid therapy 1

2. HIV-Associated Lipodystrophy

• Medical treatment of lipodystrophy itself is generally not effective 2
• Consider modification of antiretroviral regimen, particularly avoiding drugs with strong metabolic adverse effects, which may prevent or partially reverse lipodystrophy 2, 5
• The metabolic changes appear to be permanent, as discontinuation of HAART does not influence the degree of lipodystrophy 1
• Surgical treatment has shown long-term favorable effects in the majority of patients continuing antiretroviral therapy 6

Surgical Management

• Surgical intervention should be considered for patients experiencing considerable physical or psychological discomfort 6
• Liposuction is the most common surgical approach for buffalo hump removal 6
• Studies show that surgical treatment of buffalo hump has long-term favorable effects in the majority of patients continuing antiretroviral therapy 6
• Potential for recurrence exists, particularly if the underlying cause persists 6, 5

Management of Associated Conditions

• Screen for and manage metabolic complications:
  • Insulin resistance and diabetes mellitus 2
  • Hypertension 1
  • Dyslipidemia 4
  • Osteoporosis (particularly in steroid-induced cases) 1
• Body composition assessment (dual-energy X-ray absorptiometry) may be useful to evaluate fat distribution patterns 2, 4

Special Considerations

• In elderly patients or those with comorbidities requiring steroid therapy, consider alternative steroid regimens like budesonide plus azathioprine when appropriate 1
• For patients with HIV-associated lipodystrophy, recognize that buffalo hump may develop regardless of the specific antiretroviral regimen 4, 5
• Buffalo hump may persist despite normalization of cortisol levels in patients with treated Cushing syndrome 3

Follow-up

• Regular monitoring for recurrence after surgical intervention 6
• Ongoing assessment of metabolic parameters in patients with persistent buffalo hump 2
• Evaluation of bone density in patients with history of steroid exposure 1